• Physician Form Secure Submission

    Upload your completed Physician Form by 11/15/2025

    Before you submit your form, please complete the following steps:

    • Print clearly and review your form to ensure it is complete.
    • Confirm the date of screening is within the following date range: 1/1/2025-11/15/2025
    • Be sure to provide a valid email address so we can communicate with you regarding the status of your form.
    • Ensure you have signed your form. Your signature is required.
    • Ensure your doctor has signed the form. The doctor’s signature is required.
    • Only submit ONE form/upload at a time







  • Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

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